John Edward Kay · Prevention of Future Deaths report

On 3rd December 2021 I commenced an investigation into the death of John Edward Kay. The investigation concluded on the 24th June 2022 and the conclusion was one of Narrative: Died as a consequence of the recognised complications of previous necessary surgery. The medical cause of death was 1a) Recurrent Aspiration Pneumonia; 1b) Leaking Trachea-Oesophageal Fistula; 1c) Oesophageal Stricture related to treatment (surgery and radiotherapy) for Laryngeal Carcinoma; II) Chronic Obstructive Pulmonary Disease

John Edward Kay had his larynx removed for stage 4 cancer in 2010. A speech valve was put in place. He had Chronic Obstructive Pulmonary Disease and significantly reduced respiratory lung function. He was admitted to Stepping Hill Hospital where he had a series of aspiration pneumonias. He continued to deteriorate and died at Stepping Hill Hospital on 26th November 2021.

1. The Inquest heard evidence that the management of a patient with a valve such as Mr Kay had is a complex one. It requires regular monitoring and replacement. The evidence was that when he went into a care home that information about how to care for his valve was not shared with the care home. The consequence was that he was not seen or referred for regular replacements of the valve which increased the risk of the valve not functioning correctly and him developing aspiration pneumonia;

2. The role and support available from the specialist nurse service was not understood within the community including by the GP. Greater understanding and awareness of that role would have been helpful in managing Mr Kay and reducing the risk.